Tapuria Archana, Kalra Dipak, Kobayashi Shinji
Centre for Health Informatics and Multiprofessional Education, University College London, London, UK.
Department of Bioregulatory Medicine, Ehime University Graduate School of Medicine, Ehime, Japan.
Healthc Inform Res. 2013 Dec;19(4):286-92. doi: 10.4258/hir.2013.19.4.286. Epub 2013 Dec 31.
The objective is to introduce 'clinical archetype' which is a formal and agreed way of representing clinical information to ensure interoperability across and within Electronic Health Records (EHRs). The paper also aims at presenting the challenges building quality labeled clinical archetypes and the challenges towards achieving semantic interoperability between EHRs.
Twenty years of international research, various European healthcare informatics projects and the pioneering work of the openEHR Foundation have led to the following results.
The requirements for EHR information architectures have been consolidated within ISO 18308 and adopted within the ISO 13606 EHR interoperability standard. However, a generic EHR architecture cannot ensure that the clinical meaning of information from heterogeneous sources can be reliably interpreted by receiving systems and services. Therefore, clinical models called 'clinical archetypes' are required to formalize the representation of clinical information within the EHR. Part 2 of ISO 13606 defines how archetypes should be formally represented. The current challenge is to grow clinical communities to build a library of clinical archetypes and to identify how evidence of best practice and multi-professional clinical consensus should best be combined to define archetypes at the optimal level of granularity and specificity and quality label them for wide adoption. Standardizing clinical terms within EHRs using clinical terminology like Systematized Nomenclature of Medicine Clinical Terms is also a challenge.
Clinical archetypes would play an important role in achieving semantic interoperability within EHRs. Attempts are being made in exploring the design and adoption challenges for clinical archetypes.
目的是引入“临床原型”，这是一种正式且公认的表示临床信息的方式，以确保电子健康记录（EHR）之间及内部的互操作性。本文还旨在呈现构建高质量标注临床原型所面临的挑战以及在EHR之间实现语义互操作性所面临的挑战。
二十年的国际研究、多个欧洲医疗保健信息学项目以及开放EHR基金会的开创性工作带来了以下成果。
EHR信息架构的要求已在ISO 18308中得到整合，并在ISO 13606 EHR互操作性标准中被采用。然而，通用的EHR架构无法确保接收系统和服务能够可靠地解释来自异构源的信息的临床意义。因此，需要称为“临床原型”的临床模型来规范EHR中临床信息的表示。ISO 13606的第2部分定义了原型应如何进行正式表示。当前的挑战是发展临床社区以建立临床原型库，并确定最佳实践证据和多专业临床共识应如何最好地结合，以在最佳粒度、特异性水平上定义原型并为其标注质量标签以供广泛采用。使用诸如医学临床术语系统命名法之类的临床术语在EHR中标准化临床术语也是一项挑战。
临床原型将在实现EHR内的语义互操作性方面发挥重要作用。目前正在尝试探索临床原型的设计和采用挑战。
